Animal Bite Investigation Form
Animal Bite Investigation Form
Shaded areas are mandatory for reporting to Saskatchewan Ministry of Health
[Indicates field in iPHIS]
Please use yyyy/mm/dd for all dates
Date:
Client Information
|Victim’s Name: | Male |DOB: |
| |Female |Age: |
|PHN: | | |
|Parent/Guardian (if victim is a minor): |Phone number: H: |
| |W: |
|Mailing Address: |Postal Code: |First Nation: |
| | | |
|Attending Physician or Primary Care Nurse: |Attending Physician/Nurse |Date first attended by Physician: |
| |Phone number: | |
|Previously immunized for Rabies: Yes Unknown No |Date immunization completed: |
Incident & Initial Assessment
|Date of Exposure: |Unique Animal ID Number:[1] |
|Place of Exposure: Name of town/city (if within city limits) OR RM (rural) OR First Nations Community: |
| |
|Type of Exposure:[2] Bite Scratch Saliva on intact skin Saliva on existing lesion Saliva on mucous membranes |
|Occupational - Bite Occupational - Scratch Occupational - Saliva on intact skin |
|Occupational - Saliva on existing lesion Occupational - Saliva on mucous membranes |
|No known contact Other , specify: |
|Type of attack: Provoked Unprovoked Unknown |
|Wound Location: Head/Neck Face Arm Hand/Finger Torso Leg Foot/Toe Mucosa Unknown Other , specify: |
|Animal Species: Dog Cat Bat Cow Horse Skunk Racoon Hog Fox |
|Other , specify: |
|Animal Type: Pet (indoor) Pet(outdoor) Pet(indoor/outdoor) Outdoor Farm Animal Wild Stray Unknown |
|Animal healthy at time of incident: Yes Unknown No |
|Symptoms: |
|History of Incident/Exposure: |
|Animal Vaccinated: No Unknown Yes , please provide details/dates: |
|Veterinarian: |Vet Phone number: |
|Owner Name: |Address: |Phone Number |
| | |H: |
| | |W: |
|Observation Following Exposure: No Yes Where? |Date Observation Completed: |
|Animal Retention Result: Became ill Released Natural death Destroyed Escaped |
|Brain Sent for Testing? Yes Date sent: |No Why not? |
|Primary Lab Results: Positive Negative Final Lab Results: Positive Negative |
Immunization Recommendation
|Tetanus Indicated? Yes No |
|Administered? Yes Date: No Why not? |
|Rabies Immune Globulin & Vaccine: |
|Recommended Not recommended Unknown at this time If recommended, complete immunization record (below) |
|Date received: |Date MHO Review: |Date sent to CFIA: |
|Immunization Information |
|RIG Dosage: Weight in kg = × 20 IU / kg = I U (2 mL vial contains 300 IU = 150 IU/mL) |
|= mL |
|Date: |Site(s)/Amount (ml) |Administered by: |
|Prior to initiation of Rabies Post Exposure Prophylaxis, all persons must be screened for immunosuppressive disorders which may include: ( Asplenia; ( Congenital |
|immunodeficiencies involving any part of the immune system; ( Human immunodeficiency virus infection (HIV); ( Immunosuppressive therapy; ( Haematopoietic stem cell|
|transplant (HSCT) recipient; ( Islet cell transplant (candidate or recipient); ( Solid organ transplant (candidate or recipient); ( Chronic kidney disease; ( |
|Chronic liver disease including hepatitis B and C; and ( Malignant neoplasms including leukemia and lymphoma. |
|(). Consultation with the MHO should be done in case of any significant illness or for |
|clarification if a candidate for rabies vaccine may be immunosuppressed due to the clinical condition or therapy. |
|Vaccine |Series |Date |Administered by |If series not completed, why not? |
| | | | |Animal well after observation period |
| | | | |Animal results negative |
| | | | |Victim previously immunized |
| | | | |Victim refused further doses |
| | | | |Lost to follow-up |
| | | | |Referred out of province |
| | | | |Other |
| |1st Dose | | | |
| | | | | |
| |Day 3 | | | |
| | | | | |
| |Day 7 | | | |
| | | | | |
| |Day 14 | | | |
| | | | | |
| |Day 28* | | | |
| | | | | |
|Remarks (e.g. vaccine reactions): |
|*Only required for immunocompromised individuals |
Return completed form to Regional MHO
|Health Region/Authority: |
|Reported by: |
|Job Designation: |
|Phone: |Fax: |
|MHO or Designate Signature: |Date: |
-----------------------
[1] This is a unique animal identifier that should be used in each case report on iPHIS that involves the same animal in the following format: --- (e.g. SCHR-2007-R-001. This is to be documented in iPHIS in the “Animal Services Incident Number” field.
[2] Occupational exposures are when the person is exposed through performing job duties (i.e. a mail carrier bitten would not be an occupational exposure, however a veterinarian handling a sick animal would be).
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